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40 THE NOSE AND PARANASAL SINUSES
an irregular mamillated infiltration, dark red in colour, involving one or both
sides of the septum. Usually at this stage the only symptom is nasal obstruc-
tion, but there may be headache and severe pain in the nose, which may be
swo lien and tender. When ulceration occurs it is accompanied by a purulent
discharge which tends to dry and form crusts which emit a horrible stench.
After removal of the crusts by douching the nose may be more fully inspected.
If the septum is affected it will be found to be perforated, and the perforation
usually involves the bony structures as well as the cartilaginous portion. If the
process is still active the edges of the perforation will be covered with
granulations. The loss of tissue may be so extensive that there may be sinking
of the bridge of the nose and even ulceration and destruction of the external
nose. The structures of the lateral wall of the nasal cavity may also be
extensively ulcerated and in part destroyed.
DIAGNOSIS. The diagnosis is not difficult as a rule, but syphilis must be
distinguished from ozaena, tuberculosis and lupus. In ozaena the foetor is
different and septal perforation does not occur. Tuberculous ulceration of the
nose is almost always secondary to some other tuberculous lesion, and it is
not accompanied by foetor. In lupus there is not the rapid loss of tissue found
in syphilis, and there is usually nodular infiltration of a characteristic nature.
In all doubtful cases the serological tests should be carried out.
TREATMENT. Penicillin is the treatment of choice. The nose should be kept
clean by frequent douching with mild antiseptic solutions, and all loose
sequestra should be removed.
Tuberculosis very rarely affects the nose. It takes the form of a tumour which
may produce ulceration and destruction of tissue (Plate 1,4). If it appears as a
granular growth arising from the septum it may be mistaken for a sarcoma,
but histological examination will show the granulation tissue and tuberculous
giant cells. The septum is most commonly ulcerated, usually in its cartilagin-
ous part, and perforation soon follows. Occasionally the lateral wall of the
nasal cavity is affected.
SYMPTOMS. These are slight. Ulceration gives rise to nasal discharge, but
pain is generally absent.
DIAGNOSIS. The diagnosis has to be made from syphilis and lupus. In
tuberculosis the perforation affects the cartilaginous septum while syphilis
involves the bony septum as well. There is evidence of tuberculosis or syphilis
in other parts of the body. In cases of doubt serological tests and biopsy will
provide the solution. Lupus is distinguished by nodular formation and skin
TREATMENT. As a rule, tuberculosis of the nose resolves on a full course of
streptomycin, sodium aminosalicylate (PAS) and isoniazid.
In the nasal cavities lupus is more commonly met with than tuberculosis.
Young persons, especially females, are attacked, and the disease is extremely
chronic. It is often associated with some cutaneous lesion, and it is possible